The loss of a child, bereavement and the search for meaning: A systematic review of the most recent parental interventions.

The loss of a child is considered one of the most tragic experiences that parents can go through. The present systematic review aims to compile the most recently published interventions in bereavement support for these parents, being particularly interested in those made from a meaning-centered approach. The search for the units of analysis was guided by the standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement and was entered in Web of Science, Scopus and EBSCO, obtaining a total of 485 papers of which 21 have been included in this article. The results found are heterogeneous in terms of the type of intervention used and results, but they all seem to have something in common: the lack of research and reliable interventions that exist for this population. With this systematic review we intend to achieve a better understanding of these parents' needs and to highlight the enormous work that still remains ahead in order to make their bereavement experience a little less devastating.

Introduction

According to the United Nations International Children's Emergency Fund (UNICEF) at the present moment, a total of 15,000 children under the age of five die on a daily basis and an additional 60 million will die between now and 2030 (Aparicio., n. d). When you think of these figures in terms of the number of parents that will lose their children, it becomes clear the amount of parental bereavement our world is currently facing and will face in the future. However, it is important to keep in mind that all these grievers will not react to the loss in the same way, nor are all their grievances will be identical (Burke et al., 2014).

In fact, over the years, different types of bereavement have been developed across literature. An example of this is family bereavement, which is described as an adjustment period characterised by a range of emotions, behaviors and thoughts which enables both individual and family equilibrium to be restored after a loss (Porta et al., 2013). Even more specific is the concept of parental bereavement, which is conceptualised as a never-ending process in which parents experience a completely new reality (Denhup, 2017). This particular type of bereavement is composed of the following phases: a phase of shock and denial, a phase of acute distress and isolation and, finally, a reorganization phase (Porta et al., 2013).

However, between 10 and 34% of cases, grief is not experienced in a normative way and becomes pathological (Ballestín et al., 2007). This grief is defined as an intensification of specific symptoms that lead the person to engage in maladaptive behaviors that interfere with the ability to heal, resulting in the person becoming completely overwhelmed (Neimeyer & Ramírez, 2002). Even more, this pathological grief has also been predictive of insomnia, substance abuse, cardiovascular disease, social problems and suicide attempts (Burke et al., 2014).

Continuing, if this grief did not already have enough negative impacts on its sufferers, it has also been known to possess an addictive quality. This is explained in the paper published by Burke et al. (2014), claiming that, while the brains of people suffering from normative grief have a greater activation in their brains' pain pathways when seeing the photograph of a deceased relative, in the case of people suffering from complicated grief, the nucleus accumbens is the brain structure with the greatest activation when viewing this same picture. This is therefore worrying when remembering that this nucleus is the responsible for managing the reward system and addiction processes. Something which confers it with the capacity of developing an addiction to this type of suffering among its mourners, making complicated grief even more threatening.

Many risk factors exist for the development of this type of grief, but we particularly highlight the fact of experiencing the loss of a child (Porta et al., 2013), being the caregiver of the deceased person and, finally, the cases where the intensity of attachment is high. This last risk factor receives special support from Neimeyer and Ramírez (2002), which point out that the severity of the emotional reaction to the loss is proportional to the existing affective relationship between the bereaved and the deceased.

It can be observed then, that all these risk factors point to parents who lose a child as a very suitable target to experience such an adverse reaction. This, parallel to the fact that in our current society we have been taught that everything can be understood from a logical point of view (Porta et al., 2013) and that the death of a child is inconceivable and impossible to integrate as it is unnatural, endows these losses with the capacity to be highly traumatic (Ballestín et al., 2007). The biological theory of grief further emphasises this by explaining that, in the course of evolution, irretrievable losses are not understood in a logical way and that our whole system is mobilised to re-establish the contact with the lost one. This primary instinct that leads us to believe that losses are reversible, despite the desire to be adaptive, can make the suffering experienced by parents at this time even more intense (Neimeyer & Ramírez, 2002).

In addition, as far as our Western society is concerned, it also contributes to suffering by among other things, harbouring a strong taboo on death, as it brutally clashes with a welfare state that seems to prevail above everything else. Thus, loss and its corresponding grieving process tend to be neglected, as they represent a rupture with this state of wellbeing that is so central in today's culture. It is not surprising, therefore, that bereaved people tend to feel misunderstood, isolated and inexperienced in dealing with their grief, something which can greatly exacerbate the repercussions of their loss. In fact, this lack of knowledge will lead them to use the strategies that our culture instils in us: those based on logic. However, although these are functional and suitable in our day-to-day lives, they are not able to relieve their anguish and pain, and, as mentioned above, may further aggravate them (Porta et al., 2013).

In fact, along with the loss of a spouse, the death of a child is considered by the Social Readjustment scales to be the most difficult experience that a person can go through (Ballestín et al., 2007). And not only this, Neimeyer and Ramírez (2002) claim that, from a physiological point of view, the loss of a loved one can be equivalent to the pain experienced by a severe wound or burn. Adding to this, it must be noticed that several studies have found that these parents tend to suffer serious health problems along with a higher mortality rate (Denhup, 2017). These notions, together with the fact that unresolved grief over the loss of a child can contribute to pathological relationships that extend over several generations and the existing knowledge that the degree of support perceived by the family is significantly related to better bereavement outcomes, makes it vitally important to provide these families with assistance (Neimeyer & Ramírez, 2002).

This is the reason why, taking into account all these factors and the psychological vulnerability that bereaved parents encounter, a number of specific therapies have been developed over the years for this population. Some examples are the cognitive-behavioral grief-targeted intervention, which is able to considerably reduce the negative effects of bereavement (Lichtenthal & Breitbart, 2015). Group therapy, which, in addition to being effective and reducing levels of depression (Burke et al., 2014), provides parents with crucial emotional support (Jordan & Litz, 2014). Family therapy, which holds that family members may grieve differently but also grieve together as a unit (Burke et al., 2014), and, finally, the most recently developed: internet based interventions (Jordan & Litz, 2014).

Nevertheless, at the time of this review, we are particularly interested and curious in one specific type of approach, being this meaning centered psychotherapy. As a fundamental basis, this therapy posits that human beings have a unique capacity to find meaning in even the hardest life experiences (Wong, 2010) and that grief is actually an existential crisis that, depending on how we deal with it, gives us the opportunity to grow and build a life worth living or, on the contrary, feeling an unresolvable void (Porta et al., 2013). This existentially oriented therapy, initially developed for chronic cancer patients by Breibart in the year 2000, was eventually adapted for the treatment of bereaved parents dealing with high levels of complicated grief (Lichtenthal & Breitbart, 2015). Although our work will mainly focus its attention on the application of this therapy for the treatment of bereavement, it is crucial to emphasise that beyond this, meaning centered psychotherapy has also been used to treat a variety of other conditions. Personality disorders is one such example, and to even be more specific, this therapy can be used for the obsessive, dependent and avoidant disorders. Adding to this, over the years, this approach has also given significant attention to addictions, sleep disorders, eating disorders, traumas, affective disorders and sometimes even psychosis. And, it has also been widely applied in oncology, disaster and family contexts (Ortiz, 2013).

Continuing, as Wong (2010) thoroughly expose in their work, this therapy possesses a multimodal nature, which can be appreciated in the fact that it has integrative, existential, relational, positively oriented, multicultural, narrative and psycho-educational characteristics. Broadly speaking, these authors state that when it is defined as integrative, it is mainly because, despite being based on logotherapy, it also includes other approaches such as the narrative therapy or the cognitive behavioral therapy. And not only this, it is also holistic in its way to approach patients, not focusing only on their condition and classifying them with any particular disorder, but understanding them as being the sum of all their selves. As mentioned above, these authors also confer a strong existential component to this therapy which provides patients with the necessary resources to make sense of their grief. It is said to be relational as it teaches how to cultivate positive and empathetic interpersonal relationships, but also when it holds and states that, as humans, we are relational beings with an intrinsic need to belong and therefore, need others. When Wong (2010) claim that it is positively oriented, they refer to the fact that it encourages patients to view themselves in an optimistic manner and to develop the belief that times will always get better, something that is also referred by them under the term of tragic optimism. Meaning centered psychotherapy sometimes also addresses problems such as discrimination, and this, among other features, is what makes it classify as multicultural. Following on, the authors also acknowledge that it represents a form of narrative therapy since it employs, for example, the use of legends to create awareness of the potential for change that we all possess inside us and use this to guide us towards our chosen future. Finally, the therapy is considered to be psycho educational as it enhances the ability to create meaning at the same time it equips patients with tools that will serve them throughout their lives in their daily functioning.

But, when we mention meaning, what are we really referring to? On what does the well-known concept of meaning in life consist? At this point it is necessary to mention that despite the name given to this therapy is meaning centered psychotherapy and that meaning is present during the entire therapeutic process, this therapy not only focuses on the problematic of meaning. It is also worth considering that, in addition to this, this approach recognises two different typologies of meaning. One in terms of the perspective taken in particular situations (situational meaning) and another in terms of the meaning that is discovered through the experiencing of these situations (Ortiz, 2013). Continuing with the attempt of describing this complex concept, Neimeyer (2015), bring further explanation stating that meaning in life is understood as the ability to reconstruct a world whose meaning has been shattered by the death of a loved one. Even more, authors claim that meaning is what makes suffering more bearable, and its absence will lead not only to hopelessness, but depression (Wong, 2010). It has even been postulated as an adaptive mechanism aimed at reducing our distress with therapeutic benefits associated to its use, whereas parents who are unable to make sense of their child's death show higher levels of complicated grief (Lichtenthal & Breitbart, 2015). Also, in literature, the concept of meaning has been closely related to those of religion and spirituality and it has been demonstrated that mourners also make use of spiritual beliefs as coping strategies. In fact, spiritual meaning making is a broad term used to describe this connection between the concepts, and it would therefore be a mistake to assume that meaning is the only tool that ensures a better well-being amongst those who suffer losses. Proof of this is the evidence that people who are religious have an easier time finding meaning after the death of a loved one and that the creation of spiritual meaning has actually been shown to act as an underminer of complicated grief. With this, it is then observed that in addition to meaning, religion also acts as a protective factor, being able to better position those who suffer the loss of a family member (Burke et al., 2014). In fact, some empirical evidence using Structural Equation Modelling supports this idea; for instance, Bernabé-Valero (2012) defined Gratitude towards Suffering (GS) as the capacity to experience Gratitude in spite of adversity and tested a model in which this type of Gratitude (GS) was predicted by spirituality and the meaning of Life, obtaining very favorable adjustment indices.

These principles just outlined make particular sense from Niemeyer's point of view, which holds that one of the most important therapeutic tasks in dealing with grief is to make sense of the loss (Worden et al., 2013), a capacity which is greatly impaired in the course of pathological grief (Jordan & Litz, 2014). This highlights the need for a greater implementation of this therapy in which professionals are equipped with the ability to help patients find happiness and meaning, restore their hope and create a life worth living (Wheeler, 2001) as the attempt to make sense of loss has been shown to be effective, to increase the well-being of bereaved people and to reduce complicated grief symptoms (Neimeyer, 2015). As a final contribution of this therapy to this field of intervention, we add the observation that those who did find meaning in the study conducted by Wheeler (2001) were able to value life more, grow as individuals, care more for others and accept what cannot be changed, amongst many other benefits.

In view of these findings, it is important it to be aware of what are the main intervention strategies that this therapy can provide to achieve such results. To start with, in their paper, Wong (2015), state that this therapy uses what is known as socratic dialogue as one of its main intervention tools. This concept is based on the principle that the answers patients are looking for are already within themselves and that these can be found through a series of questions formulated by the therapist. Secondly, meaning centered psychotherapy intervenes through the double-vision strategy, a technique which makes the patient see his or her problem from a different perspective, usually being a universal rather than a personal one. In relation to perspective, this therapy also offers another strategy known as perspective taking, a technique that consists on seeing a particular situation from another person's perspective or from a different part of oneself. Next, another intervention strategy used in this approach is the so-called fast-forwarding technique, which consists in a set of methods which project the patient into the future and making him or her assess the impact that their current behavior will have on it. Next, this therapy also provides professionals with an intervention called dereflection, which has as an aim focusing patients' attention on what is truly important and to bring them to a state of self- transcendence by asking questions that distance them from their concerns. Gratitude exercises, for their part, aim to make people aware of the good things they normally take for granted or ignore. By doing so, the technique manages to bring focus on the positive aspects of life and make patients experience an enhanced wellbeing. In last place, the cultivation of intrinsic self-worth is an intervention based on the principle that self-confidence comes from oneself and therefore, patients learn through it that external validation is not necessary to feel a valid being (Wong, 2015).

In addition to all these interventions, meaning centered psychotherapy has two other fundamental resources which are considered worth mentioning. These are the PURE and ABCDE techniques. The main objective of the PURE intervention strategy (purpose, understanding, responsibility and enjoyment) is to increase patients' positivity through the use of adaptive responses in both positive and negative situations. The ABCDE technique (acceptance, belief, commitment, discovery and evaluation), on the other hand, is the main tool used to cope with prolonged negative life experiences (Wong, 2010). It is interesting that these two techniques can be combined into one by a final intervention known as the dual-system strategy, which aims to integrate and balance the negatives and the positives of life (Wong, 2015).

But what are the basic elements that must be present for these interventions to be truly effective? First of all, Wong (2010) talk about the concept of acceptance, understanding that no change will be achieved unless the patient recognizes that he/she has a problem. This state of acceptance can be achieved through the use of some techniques, such as describing the problematic in a detailed and comprehensive way or through the practice of mindfulness or forgiveness. In second place, action, described as taking responsibility for one's own life, can be addressed by the therapist through the establishment of goals and plans to achieve what is desired by the patient. Finally, during therapy there will always come a time when patients will see themselves in a new light, something referred by authors as the discovery factor. For this to happen, therapists must employ during the course of the sessions a series of interventions such as meaning construction, magic and socratic questioning, amongst others.

To the best of our knowledge, there are few studies that refer to the application of this and other types of post- death therapies for parents. In fact, over the course of the investigation, only two systematic reviews have been found in recent years that are in line with our research, and these reviews report a rather limited number of studies on the subject, altogether comprising around 30 papers (Ainscough et al., 2019; Kochen et al., 2020).

Therefore, in view of the prevailing scenario, our review intends to fill this literature gap for several reasons. In first place, it is concerning that a total of 59% of parents were not able to make any sense of the loss of their children in the study carried out by (Bonanno & Kaltman, 2001). Secondly, given the traumatic experience that this entails for the parents, it often increases marital tension, leaving them exposed to possible couple's break-ups and, either because of this or because of their state of bereavement, the remaining children do not receive the necessary attention (Neimeyer & Ramírez, 2002). This, together with the fact that we live in an era where children's admissions to health centers are growing at a frenetic pace (Ballestín et al., 2007), emphasises the need for support networks and the implementation of specific therapies for both parents and siblings. In fact, they themselves have demanded this support 80% more in recent years (Ballestín et al., 2007). Last of all, the need to raise awareness of this therapy and implement it to a greater degree is also pointed out by the fact that sudden deaths are considered to be more traumatic and do not offer the opportunity to elaborate anticipatory mourning, making overcoming this type of loss much more complex (Ballestín et al., 2007).

It is our hope then, that this review will be able to compile a number of interventions that have been effective in the last few years, both in the treatment of bereavement and in the elaboration of meaning, so that it can serve as a basis for professionals to continue to help this collective in the reconstruction and construction of a new reality.

Methods

Methodology

This systematic review was guided by the standards of the Preferred Reporting Items for Systematic Review and Meta- Analysis (PRISMA) Statement, which includes the following main stages: 1) Identification, 2) Screening, 3) Eligibility and 4) Inclusion (Moher et al., 2015).

Search strategy

In view of the current situation regarding our topic of interest, which did not have -to our knowledge- enough recently published clinical trials which prevented the option of conducting a meta-analysis and where scant research has been conducted, prior to presenting the process, it is worth mentioning and clarifying that the entire search was carried out with two clear objectives in mind: to gather as many documents as possible and to try to ensure that these were as close as possible to our interests. This is why in the course of the quest, as we saw how limited the number of documents obtained in the first searches were, we reconsidered the matter until we found the search equation that not only differentiated us from previous studies, but was also capable of increasing the results obtained. A full explanation of this process is described below.

The first step regarding the electronic search was to formulate the research equation. This was done using the PICO approach, a tool which provides a format through which investigators can accomplish this at the same time it ensures that searches made will be more precise and of a bigger quality. PICO approach stands for: Population, Intervention, Comparator, Outcomes and Study. However, as the present systematic review did not intend to compare different types of interventions with each other, component "C" (Comparator) was omitted, resulting in the format remaining as PIO (Landa-Ramírez & de Jesús Arredondo-Pantaleón, 2014). In order to ensure that the research question complied the maximum documents as possible and that that their quality, relevance and accuracy was high, the words that constituted it were selected using the Thesaurus available at EBSCO ´s database. This tool was employed to create a list of controlled terms that would give homogeneity to the vocabulary used when searching the articles in the databases (Landa-Ramírez & de Jesús Arredondo-Pantaleón, 2014). Following the same interest, PICO approach was also used to implement Boolean operators and Truncations in the search query. Therefore, the Boolean "AND" was inserted to obtain any document that included at least one of the selected key terms, whilst truncations were included to ensure the retrieval of all the linguistic variants of a search term that shared a common root (Aleixandre-Benavent et al., 2011).

Ultimately, once the research question was formulated and the controlled terms for the key words were identified, it was time to start the search to address the question that inspired this systematic review: In the last years, what has been the effect of grief interventions for parents who have lost a child? This is how, following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) standard (Moher et al., 2015) already mentioned, the search equation shown below was entered into EBSCO, SCOPUS and WOS databases during the months of October and November 2021:

After the documents had been extracted, the next step consisted in removing the articles that appeared in several of the databases. Once there were no duplicates, two stages of selection were carried out, an initial screening phase, where a considerable number of papers were discarded on the basis of titles and abstracts and a second stage known as the eligibility phase where, after a thorough reading of the articles, a second set of inclusion and exclusion criteria were applied in order to re-judge their suitability for the research (Table 1).

Table 1

Selection criteria for studies in the eligibility phase classified according to PIOS indicators

PIO indicator	Study Selection Criteria
Patient Population	Inclusion
	– Parents and families
	Exclusion
	– The sample is not well defined and hence impossible to know if the intervention was applied to parents, other relatives or to a sample that did not apply to our interest
Intervention	Inclusion
	– Post-death bereavement treatments with final measures
	Exclusion
	– Interventions that did not make it sufficiently clear whether they were interventions that sought to see effects on bereavement. No clear details on how the intervention was implemented
Outcomes	Inclusion
	– Papers showing an effect on the bereavement of parents or families: improving the process, reducing distress, relieving suffering, assisting in the search for meaning, etc
	Exclusion
	– No clear results or conclusions drawn from an experimental point of view on the impact on bereavement
Study design	Inclusion
	– Empirical Studies
	Exclusion
	– Designs that could not be replicated, use of theoretical instead of evidence-based data. Papers that resulted to be comprehensive reviews, programs, etc

Inclusion and exclusion criteria

The reasons behind the selected criteria implemented were for example, the detection of two fairly recent systematic reviews that were in some form, similar to our desired research (Ainscough et al., 2019; Kochen et al., 2020). This caused the decision of differentiating the present research from them as follows: a) By including only the work published since their last inclusion dates (June 2015), b) by expanding the age range of the sample, c) by only focusing on post-death interventions and lastly, d) by including treatments done from a logotherapic and existential approach.

Regarding the electronic search, for the reasons already mentioned concerning our area of interest, it was important to gather as much documents as possible. In this way, the only limits applied in the electronic search were dates of publication, whilst in the case of language, it was decided not apply any limit as translation would be carried out if needed. These limitations resulted in the following searches: Web of Science (2016- Present), Scopus (2016- Present) and EBSCO (July 2015- Present). These databases were chosen since they stored scientific literature at an international level, which was of interest given the scarcity of documents. Within EBSCO, with the aim to make the search as precise as we could, the only selections made were Psychinfo and Psychology & Behavioral Sciences Collection whilst in WOS and SCOPUS, all journals were included.

As mentioned above, in order to include the articles that were the most relevant to the interest of this review, PIOS approach was again used in deciding the inclusion and exclusion criteria applied in the document search at the eligibility stage. The criteria implemented in this second analysis of the documents can be found in Table 1.

Results

Study selection and screening

The results obtained and the selection process conducted for the systematic review are presented in Fig. 1. As it can be observed, the initial units of analysis consisted of a total of 485 records, which after the deletion of duplicates was reduced to 423. Next, in the screening stage, 365 articles were excluded on the basis of their titles and abstracts according to the reasons listed in Table 2. This then led to an exhaustive reading of the full texts of 58 papers, where only 21 of them were included in this qualitative synthesis. Of the 21 documents, 20 were identified during the database search, while 1 was found through the bibliography of one of the selected articles.

Fig. 1

The flow chart of the information used to answer the review question

Table 2

Showing reasons why items were excluded in the screening phase

Exclusion Criteria	Total Items Excluded
Not a parental or post-mortem bereavement intervention	153
Books, meta-analyses, journals, theses, systematic reviews	61
Sample did not include parents	46
Not a parental or post-mortem bereavement intervention & Sample did not include parents	105

Next, two tables (Table 3: Socio-demographic characteristics) and (Table 4: Main results of the studies) will be presented along with a narrative description of the interventions.

Table 3

Socio-demographic characteristics

First Author	N	Child Age at Death (range)	Country	Gender of the Parents
Aho et al	110	Stillbirth-1 year	Finland	Women:67 Men:43
Ancona et al	12	4 -25 years	Mexico	Women:6
				Men:6
Baumann et al	323	Mean: 6.66 SD:	Germany	Women:168 (52.0%)
		7.17 (a few hours—33 years)		Men:155 (48.0%)
Clarke et al	6	3 days -10 years	Ireland	Women:6
				Men:0
Edson	57	N/A	USA	N/A
Henning et al	688	N/A	USA	Women:163
				Men:137
				Not specified: 388
Janusz et al	2	N/A	Poland	Women:1
				Men:1
Lichtenthal et al	11	< 25	USA	Women:6 (75%)
				Men:2 (25%)
Machado et al	1	N/A	USA	Women:6
				Men:0
Raharjo et al	31	0.6- 23 years	Australia	Women:22 (91.7%)
				Men:2 (8.3%)
Shon	4	8 years	France	Women:1 Men:1
Snaman et al	11	N/A	USA	Women:9 (82%)
				Men:2 (18)
Snaman et al	16	N/A	USA	N/A
Suttle et al	235	Mean: 7.9 SD: 7.7	USA	Women:147
				Men:88
Sveen et al	21	Experimental:11.2SD: 4.7	Sweden	Women:14
		Control:		Men:7
		12.8 SD: 4.5
Tager et al	178	Mean: 12.9 SD:7.3	USA	Women:95 (79.2%)
				Men:23 (19.25%)
Thieleman et al	19	Before birth—adult—child	USA	Women:17(89.5%)
				Men:2 (10.5%)
Turunen et al	50	N/A	Finland	N/A
Weaver et al	6	4 days -5 years	USA	Women:5
				Men:1
Xiu et al	26	Experimental: 21.42	China	Women:18
		(0.23–49.75)		Men:8
		Control: 26.17(0.02–35.32)
Záhorcová et al	21	Mean: 23 years SD:8.49	Slovakia	Women:20
				Men:1

N/A: not available information

Table 4

Main results

First Author	Title	Year Published	N	Design	Instruments	Limitations	Main Results and Conclusions
Aho et al	The effects of peer support on post-traumatic stress reactions in bereaved parents	2017	110	Quantitative study (Pre-post without control group design)	Impact of Event Scale-Revised IES-R)	– Small, homogeneous sample and a large proportion abandoned before completion – No control group or control variables – Insufficiently described intervention	– Peer support during the family weekend was rated by parents as supportive or very supportive, important and positive – Support did not have a statistically significant impact on their stress disorders – Parents' self-perceived health, the age at which their child died, and time since passing were associated with stress reactions following the loss
Ancona et al	Evaluation of a psychotherapeutic intervention with grieving parents for the death of a child	2020		Quantitative study (quasi- experimental pre- post of a single sample)	Quality of Life Questionnaire (WHOQOL-BREF), Oviedo Sleep Questionnaire, Beck Depression Inventory-II	– The participants do not constitute a homogeneous group as the loss of children in the different parental couples was due to very different circumstances – No control group	– Significant changes were achieved in the quality of life of participants – Notable improvement in the quality of sleep – The rates of depression decreased in most of the participants through logotherapy and gestalt techniques, which allowed the elaboration of grief
Baumann et al	Prolonged Grief, Posttraumatic Stress, and Depression Among Bereaved Parents: Prevalence and Response to an Intervention Program	2020	323	Quantitative study (Pre post single- arm intervention design)	Inventory of Complicated Grief (ICG), Patient Health Questionnaire eight- item depression scale (PHQ-8), National Stressful Events Survey for PTSD—Short Scale (NSESSS), Ulm Quality of Life Inventory for Parents (ULQIE)	– Not known how the symptoms will develop in the future – The results are not generalisable and are based on self-report questionnaire data only – No control group makes it difficult to attribute results solely to treatment	– The FOR special programme improves the mental health of bereaved parents – Significant remissions of complicated grief, depression and post-traumatic stress disorder were observed between admission and discharge from the programme – However, at exit from the intervention, severe symptoms of PGD were still present in 21.1% of participants, symptoms of complicated grief in 68.1%, symptoms of depression in 22.6% and symptoms of PTSD in 30.3% – However, after participation in the programme, complicated grief symptom scores decreased significantly from pre- to post- measurement in 37.7% of the participants, depression scores decreased in 43.6% and PTSD scores were lower in 38.9% of the participating parents, while quality of life increased significantly in 56.0% of the parents
Clarke et al	Parent's Lived Experience of Memory Making With Their Child at or Near End of Life	2021	6	Qualitative study (hermeneutic phenomenological approach)		– All of the participants were recruited from the same place – Small sample size – Principal researcher knew all of the participants	– Parents experienced an extremely positive impact from memory making – The positive impact the process had on coping with grief and loss was also demonstrated, as well as an effect on helping parents to keep the memory of the deceased child alive – All parents referred that the tangible moments aided them greatly in their loss and grief – Being able to touch and feel the moulds was extremely reassuring for 4 of the families – Three participants mentioned these items as establishing a bond with their deceased child that would last long into their future life. One participant spoke about how these items helped her through rough times – Those who made sense of their loss in a meaningful way had fewer associated symptoms of complicated grief
Edson et al	Evaluating the Benefit of Bereavement Mailings at a Large Pediatric Center	2021	57	Mix-methods design (program evaluation)	22-item Likert-type Online survey	– Participants were hand-selected (selection bias) – The questionnaire was only available in English limiting responses from non– English-speaking bereaved families – Effect of the intervention on parents is unclear and more information on the sample is needed	– Forty-one parents (87.2%) found the mailings helpful 31 (66%) found the books helpful or most helpful, 23 (52.3%) found the poetry helpful or most helpful, and 32 (66%) found the pamphlets helpful or most helpful
Henning et al	The Impact of Family Bereavement Interventions: Qualitative Feedback Identifies Needs	2021	688	Qualitative study (randomized waitlist control trial)	Depression Anxiety Stress Scale – 21 (DASS-21), Family Assessment Device (FAD), Adult Dispositional Hope Scale (AHS), Connor-Davidson Resilience Scale – 25 (CD- RISC), Multidimensional Scale of Perceived Social Support (MSPSS)	– Neither dataset was prospectively designed for formal qualitative analysis – Study could not prove its feasibility	– Family or parent-focused interventions can address the specific needs of bereaved parents – Families identified benefits such as: being able to openly exchange their feelings with peers who truly understood them, gaining an understanding of individual and developmental differences in the grieving process, improving mood and coping, and enhancing relationships/communication within their families – Bereaved parents identified the benefits received from this organised peer support and affirmed that these interventions are necessary
Janusz et al	Mentalizing in Parents after Traumatic Loss. Analysis of Couple Counseling	2019	2	Qualitative study (Exploratory case study)	The Adult Attachment Interview (AAI), The Reflective Functioning Scale (RFS)	The use of an exploratory design in which only seven therapy sessions were analysed during a case study	– Grieving couple therapy helped parents in three ways: by looking for meanings in their relationship with the deceased, improving their relationships with other relatives, and by focusing on other responsibilities – The enhancement of mentalizing capacity could be a form of support in cases where this ability seems to be, as it results in the cases of complicated and traumatic grief
Lichtenthal et al	An open trial of meaning-centered grief therapy: Rationale and preliminary evaluation	2019	11	Quantitative study (Randomized controlled trial)	Prolongued Grief-13 (PG-13), Life Attitude Profile-Revised (LAP-R), Personal Meaning Index (PMI), McGill Quality of Life Questionnaire (MQOL), Posttraumatic Growth Inventory (PTGI), Continuing Bonds Scale(CBS), Depression Scale- Revised (CESD-R), Beck Hopelessness Scale (BHS), State- Trait Anxiety Scale, Positive and Negative Affect Schedule (PANAS), RAND 36-Item Short Form Health Survey, Working Alliance Inventory- Short Form	– The utilisation of a within-group design without a comparison group may limit conclusions about improvements to the influence of time – The small, uniform sample and the use of a single interventionist – Results are based on self-report surveys and the participation rate was low, explained by the difficulty in reaching out to parents	– The MCGT – The MCGT received positive feedback from participants – Significant post-intervention longitudinal outcome and results on: Prolonged grief (d = 1.70), meaning in life (d = 2.11), depression (d = 0.84), hopelessness (d = 1.01), continued bonding with their child (d = 1.26), post-traumatic growth (ds = 0.29–1.33), positive affect (d = 0 – The majority of treatment gains were sustained or increased at the three-month follow-up assessment – 16-session manualised cognitive-behavioural- existential intervention is feasible, acceptable and associated with transdiagnostic improvements in psychological functioning among parents who have lost a child
Machado et al	Therapeutic gardening: A counseling approach for bereavement from suicide	2018	1	Qualitative study (Case study)		– The external environment makes confidentiality difficult – Clients may not feel comfortable in this environment or have circumstances that limit counselling in this setting – Unpredictable weather	– Gardening served as a distraction from her pain and a cure for the pain – The participant reported that she was becoming herself again and shared that she was beginning to obtain a sense of being normal – There was a decrease in her feelings of profound sadness and guilt
Raharjo et al	An Evaluation of By My Side: Peer Support in Written Form is Acceptable and Useful for Parents Bereaved by Childhood Cancer	2020	31	Mixed-methods design	User Manual Acceptability Questionnaire	– The possibility of selection bias due to low response rate – The small sample size limits the generalisability of the findings – The under- representation of fathers and parents from diverse cultural and linguistic backgrounds, – Reliance on retrospective self- report data	– 91.7% of parents felt that the length of the book was correct—83.3% of parents felt an adequate amount of information was given on bereavement – 75% of parents found their grief reactions to be normal after the reading – 83.4% of parents and 85.7% of health professionals would strongly recommend the book – There were both positive and negative emotional responses after the reading (87.5% of parents felt comforted, 87.5% felt saddened)
Schon	Lorsque la mort d’un enfant laisse sa famille sans voix: Sur l’utilisation des objets flottants dans l’accompagnement des familles endeuillées	2018	4	Qualitative study (Case study)		– Small sample size	– A more relaxed environment was installed in which the family could create a new dynamic and a different balance – Floating objects are a very valuable tool to initiate and support emotional exchanges – The use of metaphors helped the mourners to express their experiences, to adapt to the new situation, to find a place for the deceased and to invest in new relationships
Snaman et al	Helping Parents Live With the Hole in Their Heart: The Role of Health Care Providers and Institutions in the Bereaved Parents’ Grief Journeys	2016	11	Qualitative study (Focus group)		– The effect of negative experiences between providers and families on parental grief	– The critical role played by medical institutions and staff was strongly identified by bereaved parents consistently throughout the grief journey
Snaman et al	Empowering Bereaved Parents Through the Development of a Comprehensive Bereavement Program	2017	16	Qualitative study	Own Materials	– Study not generalisable, programme results and sample not clearly defined	– Bereavement couple therapy assisted parents in three ways: by seeking meaning in their relationship with the deceased, by fostering their relationships with other relatives and by focusing on other responsibilities – Improving mentalisation capacity could be a form of support in cases where this capacity seems to be lacking, as in complicated and traumatic bereavement cases
Suttle et al	The Association between Therapeutic Alliance and Parental Health Outcomes following a Child's Death in the Pediatric Intensive Care Unit	2021	235	Quantitative study (multisite observational study Cross sectional)	Inventory of Complicated Grief (ICG), Patient Health Questionnaire (PHQ-8), Short Post- Traumatic Stress Disorder Rating Interview (SPRINT), Human Connection scale (HCS)	– Low response rate (22%) – Homogeneous and unevenly distributed sample – Reliability of the therapeutic alliance measure is unknown – Uncontrolled confounding variables (parents' responses to HCS influenced by the general alliance with specialists rather than alliance with intensivists themselves, responses could also be influenced by parents' personality characteristics and attachment styles)	– A stronger therapeutic alliance with PICU physicians is a potential opportunity to decrease symptoms of complicated grief and is associated with a lower ICG score – However, therapeutic alliance was not consistently associated with depression and post- traumatic stress disorder
Sveen et al	Feasibility and preliminary efficacy of guided internet- delivered cognitive behavioral therapy for insomnia after the loss of a child to cancer: Randomized controlled trial	2021	21	Quantitative study (two-armed randomized control trial)	Insomnia Severity Index (ISI), Prolonged Grief Disorder-13 (PG-13), Montgomery- Åsberg Depression Rating Scale (MADRS), PTSD Checklist for DSM-5 (PCL-5), Generalized Anxiety Disorder-7 (GAD-7), Utrecht Grief Rumination Scale (UGRS), Client Satisfaction Questionnaire (CSQ- 8)	– Small sample size and low statistical power	– Most parents reported positive treatment effects on insomnia and other psychological symptoms, such as: prolonged grief, depression, anxiety, post- traumatic stress disorder and grief rumination – The intervention group improved significantly from pre- to post-treatment and had a significantly greater reduction in insomnia, although the effect at post-treatment was very small (d = 0.1) – iCBT-i was feasible and was associated with reduced insomnia and psychological distress in bereaved parents, both in the short and long term and should therefore be used with parents who show comorbid symptoms – There were no significant differences between groups in response to treatment or at baseline measures on prolonged grief, depression, anxiety and post-traumatic stress, except for bereavement rumination, which was more common in the control group – However, a general trend was found for the treatment group, with overall better results than the control group
Tager et al	Participation in Online Research Examining End- of-Life Experiences: Is It Beneficial, Burdensome, or Both for Parents Bereaved by Childhood Cancer?	2019	120	Quantitative study (Correlational design)	Benefit and Burden Questionnaire	– Limited access to the survey (ascertainment bias) – Low racial diversity, – The survey was vague in some respects, could not collect accurate information – Not possible to know how many people had responded to the survey and some responses were unreliable	– More than three-quarters of parents stated that participation in the online research was at least "a small benefit", while half said they considered it at least "a small burden"
Thieleman et al	I grieve because I loved her: Bereaved parents' perceptions of a mindfulness-based retreat	2021	19	Qualitative study (constructivist phenomenological approach)		– The results obtained are highly subjective and may not be generalisable – The sample is homogeneous (mostly white women) – The researcher knew some of the participants and this may have influenced the findings	– Overall, participants viewed the retreat favourably – Benefits were found in four domains: 1) Psychoeducation (about normal grief experiences following the loss of a child, which eased participants' fears that they were somehow mourning incorrectly). 2) Mindfulness ( increasing the ability to be present and allowing distressing emotions related to grief to emerge and be experienced with an attitude of kindness), 3) Mutual understanding and support (an occasion to mourn and express grief openly and truthfully), and 4) Relationships ( facilitation of positive changes in participants' relationships with other persons as well as the establishment or maintenance of continuing bonds with their deceased child
Turnen et al	Professionally Led Peer Support Group Process After the School Shooting in Finland: Organization, Group Work, and Recovery Phases	2016	50	Qualitative study	Impact of Event Scale, Beck Depression Inventory, Audit	– Poor description of the sample	– Parents and professionals gave a positive feedback – Due to the support, families could concentrate in processing their painful experiences without the demands of everyday life—Seeing and observing other peers’ coping made their range of coping styles wider – Support groups are an effective way to assist the bereaved after a violent loss
Weaver et al	Actual Solidarity through Virtual Support: A Pilot Descriptive Study of an Online Support Group for Bereaved Parents	2021	6	Quantitative study (Pilot descriptive study)	The Technology Acceptance Model (TAM), Other Communicated Perspective-Taking Ability (OCPT)	– Limitations of this study include the limited sample size, the lack of diversity of the participants (mainly non-Hispanic white women of similar ages) and the restricted accessibility to technology	– A total of four of six parents experienced improved communication, three of six parents improved their coping skills, three of six parents felt supported by their peers, three of six parents obtained education, and three of six parents achieved emotional expression – The average scores on the technology acceptance and communication experiences scales were 4.7/5 – As indicated by the TAM survey, the virtual format was an acceptable modality of support, as parents found the system both easy to learn and enjoyable to use
Xiu et al	Prolonged Grief Disorder and Positive Affect Improved by Chinese Brush Painting Group in Bereaved Parents: A Pilot Study	2020	26	Quantitative study (Exploratory pre- post Pilot study with control design)	Prolonged Grief Scale (PG-13) (Prigerson & Maciejewski, 2007), Positive and Negative Affect Schedule (PANAS)	– Small sample size and the heterogeneity of the bereavement groups – Not consider exclusion/inclusion criteria on the age of the deceased children, the reason of death and the degree of distress of the participants – The experimental group was led by an art teacher, not a clinician	– The art practice group showed a pre-post intervention effect in the promotion of positive affect and in preventing the deterioration of prolonged grief symptoms, especially through the improvement of secondary grief symptoms and the improvement of emotion regulation – The results indicate that art may be effective in improving grief- related health, as it can improve mood and positive feelings –The intervention group had significantly higher positive affect compared to the control group, but no difference in negative affect 6 months after the intervention
Záhorcová et al	The Effectiveness of a Forgiveness Intervention on Mental Health in Bereaved Parents-A Pilot Study	2021	21	Quantitative study (Pilot experimental design)	Enright Forgiveness Inventory(EFI), Core Bereavement Items (CBI), Self- forgiveness Inventory (ESFI), Patient-Reported Outcome Measurement Information System (PROMIS), Rosenberg Self- esteem Inventory (RSEI) Adult Hope Scale (AHS), Meaning in Life Questionnaire(MLQ), Stress-Related Growth Scale-short form (SRGSs)	– Small and heterogeneous sample	– The experimental group attained a statistically greater improvement in forgiveness towards others, self-forgiveness, post-traumatic growth, a greater decrease in depression, anxiety and anger at the follow-up test four months after the end of the intervention

Characteristics of the studies included

The following table (Table 3) shows the most important socio-demographic characteristics of the included studies, such as the country where the study was conducted, the number of participants, the gender of parents and the age of their child at time of death.

On the other side, all the information that was considered important regarding the results of the investigations was collected and included in Table 4, which contains the following sections: Main author, Title, Sample size, Design, Instruments used, Main results and Limitations.

Demographic data

The included studies were published during the period from 2016 to 2021. The sample comprises 766 females while 440 are males, bringing the total number of parents who participated in the research to 1,828. The gender of 388 participants is not specified and in three of the studies gender-related data is not available. The ages of sons and daughters at the moment of death range from deceased before delivery to 49,75 years old. Studies have been carried out in several countries, with the USA being the country where most of them were conducted (47,6%), followed by Finland (9,5%), and leaving the rest of the countries evenly matched, with only one study carried out in each of them, making them represent 4.76% of the total individually.

Study designs

It has been observed that the 21 empirical studies included in the systematic review were very heterogeneous in terms of the designs used. Out of these 21 papers, ten of them were quantitative studies, nine used qualitative designs and two of them implemented both approaches, resulting in mixed methods designs. More information regarding the designs used can be found in Table 4.

Typologies of intervention

When analyzing the studies, six major typologies of intervention were identified. These were as follows: six of them used support figures as intervention tools (28,57%), four studies were carried out from Contextual and Existentialist models (19,05%), another four applied bereavement treatment through the use of objects and materials (19,05%), three of them applied online interventions (14,29%), three interventions were carried out through the implementation of family support programs (14,29%) and finally, one implemented a couple-based intervention (4,76%). Following a brief overview is presented of each of the studies undertaken in the aforementioned typologies.

Online interventions

In the case of online interventions, the study carried out by Weaver et al. (2021) consisted of an online bereavement support group via Zoom platform that lasted for a total of eight weeks. Each week, patients were explained one of the topics included in the programmes summary and received psychoeducation on it. Another study designed an online questionnaire which aimed to examine the benefit and burden parents felt when they were asked about their perceptions of their children's end-of-life experiences (Tager et al., 2019). The last intervention using this format provided virtual cognitive behavioral therapy to parents. This therapy consisted of a website containing a set of weekly modules that patients had to complete on a regular basis. Some examples of the topics included in the modules were: open questions, behavioral assignments or reading a selection of texts (Sveen et al., 2021).

Models

As for the interventions applied through different models, one was conducted through a Contextual model implementing mindfulness as a tool (Thieleman & Cacciatore, 2021) whilst three of them were based on the Existential model and the fundamental ideas of meaning-centered therapy. Out of these studies, Lichtenthal et al. (2019) implemented open trials of meaning centered grief therapy, and through this cognitive-behavioural-existential intervention, experiential exercises were performed and themes such as meaning, identity, purpose and legacy were addressed with participants. Secondly, Záhorcová et al., (2021) conducted a study where 21 bereaved parents were randomly assigned to different conditions. In this way, the control group received an educational intervention in forgiveness, whilst in the experimental group, participants underwent a humanistic psycho-educational intervention in bereavement. Finally, the last intervention identified in this review using the meaning-centered approach consisted of 14 sessions each lasting two hours, framed within Frankl's logotherapy and Worden's grief tasks (Ancona Rosas & Cortés Ayala, 2020).

Couplecounselling

Out of the 21 documents, only one described the use of couple counselling for bereaved parents. This paper specifically, consisted in the application of a mentalization intervention that consisted in the monitoring of one therapeutic process in which seven counselling sessions were examined over a four-month period. Qualitative thematic analysis was used to control the process, as through it, it was possible to see if any substantial changes occurred in the capacity to mentalize throughout the course of the treatment. Authors achieved to notice these changes thanks to the identification of certain topics in the couples’ speech and by measuring the rate at which these emerged in the following sessions.

Support

A total of six articles employed support as a bereavement intervention. However, it is remarkable that two subtypes of support have been observed, one being peer support and the second being support offered by hospitals, medical institutions and healthcare teams. Peer support was implemented in three of the studies. In first place, the investigation conducted by Raharjo et al. (2020) made use of written support in order to decrease parents’ loneliness and normalise grief experiences. This support was provided by a book created by other bereaved parents with the aim to offer assistance to those who had been recently bereaved. Secondly, another paper implemented a professionally led peer support group process where peer work took place over a period of 2 years (Turunen & Punamäki, 2016). Lastly, this type of intervention is also found in the study carried out by Aho et al. (2018) where, a family weekend support group containing candle- lighting ceremonies, musical presentations, poem recitals, and outdoor activities was used in order to reduce post-traumatic stress reactions in parents.

As mentioned, the other half of the studies explored how the support provided by medical institutions and professionals impacted on the parental bereavement journeys. The study conducted by Snaman et al. (2016) explored this effect through a bereaved parent mentoring programme containing, among other things, remembrance ceremonies to honour deceased children. Following this, the association between therapeutic alliance and parental grief was also addressed in the work carried out by Suttle et al. (2021). Here, in a multi-site observational study carried out in eight children's hospitals, authors analyzed the extent to which the therapeutic relationship between families and health professionals was associated with a better reduction of complicated grief symptoms and better general health. Last, the hematology/oncology bereavement programme created by The Boston Children’s Hospital is another example of the implementation of medical support when accompanying parents. In particular, this programme provided support to the families in the form of recurrent mailings (Edson, 2021).

Use of objects and materials

To continue, four documents have been found in which different materials and resources were used as intervention tools. The articles included contain the use of chinese brush painting, memory making decorations, nature and buttons to work on grief. This is how Xiu et al. (2020) conducted a six- month pilot study in which Chinese art practices were practiced two hours a week to see the effect they had on parental bereavement. Parents were asked to draw everyday subjects that had an important, profound and philosophical meaning in Chinese culture. Next, memory making was other of the interventions used, through which, using foot moulds, footprints and other techniques that facilitated the expression of emotions, authors studied the impact that their children's tangible memories had on parental bereavement (Clarke & Connolly, 2021). Another resource that was put in practice in one of the studies is nature. Nature, more specifically, gardening, was used as a therapeutic tool to assist a mother bereaved by suicide in the study conducted by Machado and Swank (2019). Lastly, Schon (2018) from a co-constructivist perspective and through family constellations, used buttons that symbolized each one of the family members in order to help the family overcome the loss.

Family support programs

To end, family programmes are implemented as a grief intervention in three of the studies. The first one consists in a bereavement programme at St. Jude Children’s Research Hospital where parents and families had the opportunity to participate in clinical interventions conducted by a bereavement coordinator (Snaman et al., 2016). Secondly, the study carried out by Henning et al. (2021) consisted in the implementation of two different interventions and their subsequent comparison. The first one consisted in free weekend family camps organized twice a year where families received grief psychoeducation. The other intervention described in their study involved a group intervention aimed exclusively at parents that lasted a total period of 6 weeks. For their part, Baumann et al. (2022) made use of family programmes in a 4-week family oriented rehabilitation programme (FOR), which included professionally guided group therapy sessions.

Major outcomes

The present systematic review aims to verify to what extent the most recent interventions in this field actually have a healing effect on parents. For this reason, the studies will be presented under the following headings: those that have shown benefits and those that, despite having shown some advantages in certain areas, are more inconsistent with regard to their results. More detailed information concerning these outcomes can be consulted in Table 4.

Interventions with healing effects on parental bereavement

After the in-depth analysis of the results displayed by the studies, a total of 16 documents were found to bring benefits to bereaved parents. This represents 76.19% of the total. A synthesis of these results is presented below.

First of all, two of the three studies implementing online interventions actually succeeded in positively impacting parental grief (Sveen et al., 2021; Weaver et al., 2021). Both papers agree in the fact that online interventions are acceptable as tools for dealing with bereavement. These studies report that parents gained satisfaction and acquired communication abilities. Furthermore, a pattern was present in which the intervention group exhibited a tendency to show a decrease in: grief rumination, prolonged bereavement symptoms, post-traumatic stress, anxiety and depression.

Next, four papers found that the use of Existential and Contextual models can promote meaningful benefits for bereaved parents. Lichtenthal et al. (2019) observed that meaning-centered grief therapy had an impact on symptoms of prologued grief, quality of life, depression, and hopelessness at the same time it contributed to meaning-making and posttraumatic-growth. This positive psychological change referred to as posttraumatic-growth was also reported in another paper where the experimental group experienced, in addition, two other psychological changes, these being a decrease in their anxiety and depression levels (Záhorcová et al., 2021). On the subject of Quality of life, Ancona Rosas and Cortés Ayala (2020) found that their intervention, through the use of sense- making, also contributed significantly to its improvement, by reducing the depressive state of the participants and by facilitating the development of alternative meanings attributed to the situation of loss. Lastly, in the field of Contextual models, Thieleman and Cacciatore (2021) stated that through mindfulness training, parents had the opportunity to allow painful emotions related to grief to emerge and heal, as well as changing their attitude towards their process to one of gentleness, something which made the grief journey considerably easier for them. Another benefit of this retreat was that participants were able to practice the ability to share their feelings openly and honestly with others, something that enabled them to maintain permanent links with their lost children.

For their part, Janusz et al. (2020) concluded that couple counselling helped parents in a number of ways. First of all, couple therapy was shown to be successful in alleviating the parents' traumatic grief symptomatology. Secondly, it also brought improvements to their couple relationship and their existing support system. And, finally, it was able to provide support in the parents' task of preserving a connection with their child both in a mental and spiritual way.

To continue, three of the six papers (50%) that used assistance to parents in some of the above-mentioned formats showed positive results (Edson, 2021; Snaman et al., 2016; Turunen & Punamäki, 2016). These papers agree in the fact that support, when received from professional figures and institutions either in the form of mailings, through the guidance of support groups or simply by their presence and accompaniment, relieved the suffering of the parents at this vital moment and therefore, it is a suitable form of treatment. For example, by the participation in support groups, parents were given the chance to witness how other peers in the same situation were coping with the loss as well as learning from them and enhancing their coping styles (Turunen & Punamäki, 2016). Another illustration of this is the fact that in one study, 87.2% of the participating parents felt that merely receiving mailings from the hospital was supportive and healing (Edson, 2021).

The studies conducted by (Clarke & Connolly, 2021; Machado & Swank, 2019; Schon, 2018; Xiu et al., 2020) share a number of positive outcomes associated to the use of materials and resources as grief interventions. In the case of the implementation of materials to create tangible memories of the deceased, it was observed that, memory making aided parents to experience less symptoms of complicated grief and was seen by the parents as hugely comforting and beneficial (Clarke & Connolly, 2021). Furthermore, the maladaptive emotions of guilt and sadness experienced by a mother bereaved by suicide were diminished by the use of gardening and nature as resources, as it can be appreciated in the study conducted by Machado and Swank (2019). Next, buttons were proved to be a valuable tool for intervention as they contributed to the creation of a new dynamic within the family that facilitated their grieving process, both individually and collectively. This was accomplished by: facilitating the expression of emotions and experiences within the family, helping them to adapt to the new situation, placing the deceased daughter in a place in the family system that allowed them to move forward and, ultimately, creating new and valuable connections between them (Schon, 2018). The effects of brush painting in the process of grief are shown in the study conducted by Xiu et al.(2020). Here, authors noted that, in comparison to the control group, grieving parents who painted were more likely to prevent prolonged grief symptoms, experience positive mental health outcomes, have a better emotional regulation as well as a better mood. However, brush painting, in addition to these benefits, showed some results that were less promising. These will be described in the next section.

To end, Snaman et al. (2017) found that the participation in family programmes positively impacted the grief experience experimented by bereaved family members. More concretely, 81% of parents when asked about the usefulness of one of the components of the programme, indicated that it was helpful and beneficial for them. Next, another positive impact of a family bereavement intervention was observed in the results obtained by Henning et al. (2021). The authors state that both groups of participants identified benefits such as: improved mood and coping capacities, enhanced relationships and communication within their families, as well as a better overall mental health due to their involvement in the intervention.

Interventions with less conclusive effects

On the other hand, the next section will describe the five studies (23,81%) that, while showing some positive results, also show more ambivalent conclusions in terms of their impact on parental bereavement. In the case of Raharjo et al. (2020), whilst 87,5% of the parents felt comforted by the reading of the book, the exact same number (87,5%) presented a negative emotional reaction to it, stating a feeling of sadness after the lecture. Next, as already argued, the pilot study conducted by Xiu et al. (2020) showed overall positive results, but no effect of the intervention was found in the negative affect of the participants, making their negative emotions remain the same once the experiment had concluded. Third, another study with mixed results was the one conducted by Tager et al. (2019), which found out that the participation in their online survey was perceived as a small burden by half of the parents who were involved. Adding to this, another paper with less redundant results was the one designed by Suttle et al. (2021). In this paper, therapeutic alliance was shown to have several benefits for parents, but was not associated with better health, remissions in depression or in post- traumatic stress symptoms. Following, Baumann et al. (2022) concluded that their intervention brought significant remissions in symptoms of complicated grief, but these symptoms were still present when parents left the programme, making the findings for this experiment doubtful. Even more specifically, authors found that 21.1% of participants still experienced severe symptoms of prolonged grief disorder, 68.1% maintained the symptoms of complicated grief, 22.6% still had depression symptoms, and 30.3% of them remained with symptoms of PTSD. Last of all, it was found that despite having a positive effect in some areas, the peer support intervention designed by Aho et al. (2018) did not succeed in ending the stress responses of the parents who had lost a child.

Discussion

The purpose of this systematic review was to compile the most recent interventions conducted in the last few years, to examine how beneficial they have been for the support of parents in their grieving process and to see if meaning- centered therapy is being implemented with the sufficient constancy in this area.

It has been found that the 21 interventions carried out in the last 6 years have -for the most part- been helpful in dealing with bereavement. However, despite showing this favorable trend, the included interventions have an enormous heterogeneity in terms of their designs, highlighting that research in this area is not particularly consistent and that there are no properly established lines of intervention. This confirms one of the hypotheses we had prior to conducting the review and is coherent with Endo et al. (2015), which already pointed out the impossibility of comparing the effectiveness of different interventions due to their heterogeneity. In addition, of the 485 studies retrieved in the preliminary search, the vast majority had nothing to do with the treatment of parental bereavement, and the recruitment of papers that actually met our criteria was a laborious process. This supports another of our hypotheses: the paucity of empirically validated studies on this topic, something also mentioned by Ainscough et al. (2019).

With regard to the literature already existing at the time of this review, it is worth stating briefly that the two aforementioned systematic reviews already offered a number of findings similar to ours (Ainscough et al., 2019; Kochen et al., 2020). For their part, Ainscough et al. (2019), also agreed on the lack of rigorously conducted studies with control conditions and how this which greatly limits the reliability of most studies. The recognition of the methodological problems that exist in most of the published papers is also shared by Kochen et al. (2020). The results obtained are also in harmony with previous ones in the tendency to show a decrease in depression, stress disorders and stronger personal growth as a consequence of the implementation of some of the interventions. However, even though these pre-post effects are observed across the reviews, results, in most cases, do not reach the required threshold to be considered significant, questioning whether the latest interventions actually provide the necessary accompaniment for the bereavement of these parents. Agreement is also found in the fact that throughout the papers the positive effects of support, remembrance and psychoeducation are consistent.

However, there are cases where the conclusions obtained do not coincide with the findings of prior systematic reviews. This may be attributable to the heterogeneity of the work in this field, which makes it very challenging to compare the current literature with that of our own. Keeping this in mind, our results differ from those previously obtained as follows. First, it has been observed that other systematic reviews refer exclusively to interventions carried out by hospital staff whilst this paper comprises interventions conducted by researchers, psychologists, institutions and other figures. As well as the studies led by different professionals, the same applies to the variables under analysis, as, different kinds of them are measured in the encountered reviews, something which again complicates any kind of comparison between the results presented. However, being aware of these differences but momentarily putting them aside, it is true that contrary to the trend observed for the results of Ainscough et al. (2019), this review is able to present several examples of significant results within its selected papers. Examples of this can be found in the study conducted by Edson (2021), which managed to obtain significant outcomes for prolonged grief, meaning in life and depression and in the case of the participants undergoing the study conducted by Ancona Rosas and Cortés Ayala (2020), which achieved significant changes regarding their quality of life. This might be explained by the fact that these results belong to quasi-experimental pre-post and randomized controlled trials and are, therefore, able to provide more solid and valid conclusions. The same is true for the age of the children at the time of their death. While the last published paper (Kochen et al., 2020) focuses on perinatal deaths (understood as the death of the fetus or newborn within the perinatal period, that is, from the 28th week of pregnancy until the first week of life), our review covers a much wider range of age as we believe that although the children are grown adults, they still have the capacity to reverse the life of their parents with their death (Wheeler, 2001).This could also be significant when comparing results as, depending on the age and causes of death, the psychological reaction, and therefore the response to the intervention, may be different (Ballestín et al., 2007).

There are instances, however, in which the results of this study are able to provide a number of new insights in relation to the most recent reviews and existing theory. For example, it has become clear that there is an abysmal difference between the participation of men and that of women. This is alarming as it indicates that currently, there is minimal support for fathers who experience the death of a child and that the male population may not be receiving the assistance they need to grieve in a healing way. This reality was already mentioned by Cacciatore et al. (2013), which stated that fathers, when dealing with the loss off child, report feeling neglected by their professional and personal environment as they are often attributed a less severe grief than that of their partners. The need for inclusiveness in these interventions is also highlighted by two other discoveries, being this the fact that most of the studies include samples composed solely of white women and the limited accessibility that exists to some of the interventions included, some of them being only available in English and for those with access to the internet and computers. This highlights how many people may currently be excluded from receiving assistance simply because of their language, country or technological acquisitions.

Once having discussed our results with the already published literature, it is important to emphasise the initial objective of this work. As it has been mentioned throughout the document, the task of finding interventions carried out in recent years for this specific population group was costly, and, not only this, the conclusions that can be drawn from many of those that we did manage to recover, are in many cases inconclusive. Nevertheless, it should be added that, despite the limited number of papers, the most recently published interventions have been able to mitigate to a large extent many of the negative symptoms experienced by parents.

It has already been mentioned that in terms of intervention typologies, the type of intervention that we have been able to recover the least amount of documents is Couple Counselling, with only one intervention focused on this field when it has been shown to have great potential when it comes to increasing the social bonds of these parents, something that is of vital importance to them. This importance is also reflected in the fact that interventions that use support as an intervention account for the majority of the articles in our work, making them the two most popular and most widely implemented in the field.

Following, the positive effect of the implementation of meaning-centered therapy has also been observed and included, something that—to our knowledge—has not been done in any other systematic review. Effects such as reductions in prolonged grief, depression and hopelessness in combination with the limited number of interventions found from this approach, point to the importance of a greater inclusion of this model in bereavement counselling. In his work, Neimeyer (2015) also supported this claim by stating that not being able to find meaning was associated with prolonged and complicated bereavement symptoms in parents who had lost a child. Adding to this and to conclude, other systematic reviews have not included the utilization of online support techniques for bereavement. Something that, in our opinion, is essential due to the implementation of online psychological support as a consequence of the Covid-19 pandemic that spread across the world in the year 2020. This review underscores that these tools are able to promote helpful coping skills even at times when, due to restrictions or distance, parents are unable to physically receive this help. Jordan and Litz (2014) further highlight the benefits of this intervention modality by presenting evidence that in a 5-week email-based intervention, parents experienced a significant reduction in PGD symptoms compared to those in the control group.

As noted above, the inclusion of this type of therapy is both new in the field and one of the main reasons behind the present paper's research. However, although this article is sufficient to extract a brief outline of the benefits of this type of therapy in parental bereavement, three interventions are insufficient to draw any clear conclusions. Nevertheless, as described in the results section, it has been observed that, broadly speaking, this type of intervention has been able to reduce, among many things, prologued grief disorder and that the ability to confer meaning to this experience produces noticeable beneficial effects.

It has also been pointed out that not everything is positive in this field and that some of the interventions described do not offer significant benefits. However, we remain optimistic that these and other obstacles we have uncovered in the course of this research are learning opportunities for the sector to gradually learn how to better support bereaved parents.

Limitations and future investigations

However, our work has certain limitations. One of them is that, given the small sample of documents obtained at first, the search equation was expanded considerably, gathering too much information that in most cases was not useful. As a result, we also obtained very diverse documents from where it was difficult to obtain common results. This highlights the need to include stricter selection criteria in terms of methodology in future research. Continuing, trends for improvement are observed in most interventions but these are usually not significant and many of them are based on self-reported data, which decreases the results' reliability and the enthusiasm for the positive effects observed. Lastly, one of the objectives was to include meaning-focused therapeutic interventions and a small number of them were found, making their contributions in this review not very representative as a whole. Nevertheless, despite its limitations, this study provides a representative picture that we consider adequate as a basis for future systematic reviews conducted in this particular field.

We recommend that future investigations include control groups and robust designs such as randomized controlled trials to truly test the effect these interventions have on parents, and as already mentioned, to be more inclusive in terms of gender and age. Furthermore, it would be interesting to conduct further investigations that work from an Existentialist model and use meaning in life as an experimental variable. Last, we would like to encourage Spanish researchers to further exploit this field, since in 2020, out of every 1,000 births in our country, 2.66 children under the age of one died, no intervention has been published in Spain in recent years and literature clearly exposes the need to design more validated and efficient interventions for this population.

Conclusions

Overall, although the results of the reviewed papers point to the usefulness of bereavement interventions, further methodological strength is needed for meta-analyses to be carried out in the future. Within the typologies, the effectiveness of the meaning-centered grief therapy is highlighted. However, given the existing heterogeneity within interventions and their scarcity, it is not possible to determine to what extent their results are specific to their approach and therapeutic procedure. This review calls for the need for psychologists and health professionals to actively work in this field in order to address the flaws that have been identified.